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Progress Spring, 1999

Index

Dealing with the Emotions of Cancer

A Personal Perspective

Cancer Director Named to newly Endowed Professorship

Research Roundup - Bone Marrow Transplantation:
Targeting Neuroblastoma
Kinder, Gentler Transplants for Older Patients

Harnessing the Immune System - New Bone Marrow Transplant Director Aims High

Cancer Center Offers Post-Treatment Breast Cancer Nutrition Classes

MARCH Deemed a Success!

Spring to Life Benefit

Transplanting Courage

BMT Glossary

U-M Peer Counseling Program

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Dealing with the Emotions of Cancer
New Psycho-Oncology Program Will Offer Solutions

"Am I going crazy?" Cancer patients often ask themselves this question, but according to psychiatrist Michelle B. Riba, M.D., M.S., the answer is usually no. "However there are a lot of reasons to feel overwhelmed and anxious," she explained at a recent Cancer AnswerNight, "The Blues, the Blahs and the Pits: Dealing with the Emotions of Cancer."

"The distress is most difficult right at diagnosis and after treatment is complete, when the person re-enters his or her normal routine," says Riba.

Emotional distress can be caused by any number of factors, including uncertainty about the future, pain, side effects of treatment, feelings of isolation or guilt, information overload, worries about recurrence, physical limitations, as well as financial and family problems. In addition, there may be psychiatric symptoms that pre-date the cancer diagnosis.

Furthermore, patients often don't realize that chemotherapy, surgery and other treatments can directly cause or contribute to their psychological condition.

So is it normal for cancer patients to be depressed and anxious?

Riba says depression and anxiety are very common 50 percent or more of cancer patients have depressed mood or anxiety or both at various times. Symptoms may include difficulty concentrating, inability to carry out one's usual daily routine, intrusive thoughts and fears about their diagnosis and the future. "But it's very important for people to seek professional help if these symptoms last for more than a few weeks," she says.

To help patients better cope with the emotions of cancer, Riba will lead the new Psycho-Oncology program, a collaborative effort between the Department of Psychi-atry and the Cancer Center's Behavioral Oncology program, directed by Bernadine Cimprich, Ph.D. The Psycho-Oncology program will strive not only to improve patient care, but also research and health professional training.

Patient care
At the Cancer Center, psycho-oncology services are provided by a wide variety of professionals psychiatrists, psychologists, social workers, nurses, physicians, nurse practitioners, clergy and education specialists. Patients and their families are either seen individually or in group settings.

"While most of the groups are either supportive or educational, our new Psycho-Oncology program plans to expand services by providing cognitive-behavioral, interpersonal, relaxation and insight-oriented group therapies," says Riba. "Currently, groups tend to be diagnosis-based (for example breast cancer or melanoma), but we plan on looking at common themes (such as going back to work or marital issues) as a way of providing additional assistance to patients and families."

Riba cites the work of David Spiegel, M.D., and colleagues at Stanford University, who published findings that show supportive/expressive group psychotherapy extended the survival time of patients with metastatic breast cancer. Since then Riba says there have been important advances in the relationship of psychiatric issues and cancer. For example, studies have shown:

  • positive effects of psychiatric intervention on recurrence and survival in malignant melanoma patients;
  • reduction of pain in metastatic breast cancer patients who receive both group therapy and hypnosis; and
  • a psychobiological relationship between emotions and the aggressiveness of certain types of tumors such as gliomas.

Research
According to Riba, researchers have tried for decades to determine the relationship of such factors as depression, anger, personality traits, suppression of emotions, stress and others to developing and surviving cancer. "To date, there have been no large-scale studies to confirm that any of these factors increase the likelihood of getting cancer and surviving cancer," she says.

Drawing on the resources of the U-M's Institute for Social Research, Department of Psychiatry, Mental Health Research Institute and the Cancer Center, Riba expects to:

  • better understand interventions that can help patients adapt to illness;
  • develop ways to enhance and measure patients' quality of life;
  • improve interventions to change cancer-causing behaviors (e.g., smoking); and
  • pioneer psycho-biological research (e.g., studying the psychiatric side effects of standard and new cancer treatments).

Education and Training
Educating medical students, staff, patients and the public is another key goal of the program. Through ongoing case-conferences and public seminars on understanding the psychological dimensions of coping with cancer, Riba plans to heighten awareness of this important issue. In addition, oncology fellows are now trained to assess and treat psychiatric symptoms.

Riba hopes the new program will provide the best possible psychological care for patients; help students and health care professionals better communicate with patients and families about emotions; and lead research efforts to understand the psychological factors that may improve quality of life for cancer patients and their families.

"So many patients think they are the cause of their anxiety, or if only they were stronger, they would not feel so depressed," explains Dr. Riba."And to complicate matters, many health care professionals haven't been trained to recognize and treat these conditions. We plan to change all of that."

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A Personal Perspective

by Michelle B. Riba, M.D., M.S.

My younger sister and I grew up in New York City in the 1950s and 60s with loving, well-educated parents and a good home. But what colored and pervaded our lives was our mother's cancer hospitalizations, treatments, pain and worry.
Michelle B. Riba, M.D., M.S.
Throughout it all, my sister and I never met or talked to her physician. In those days, hospitals had a lot of rules against children visiting, so even that was difficult.

Our friends hardly knew about our mother's condition. They didn't ask, and we didn't tell. It felt like a stigma for all of us. I remember writing an essay for English class on "Depression and Cancer." The teacher wrote "Good job" but never talked to me about what I was writing, my family, etc. I guess I was asking for some help but never got it.

My sister and I were not part of any discussions on what to expect or how to cope. Our mother was kept in the dark about her grim prognosis, but I have always wondered if she really believed what the doctors were telling her in the face of a worsening physical condition.

It occurred to me then that cancer affects the entire family. In my own primitive way, I recognized that there was a deep emotional aspect to cancer and that there was a relative absence of knowledge or assistance that should have been provided. My personal experiences have clearly shaped and fueled my very focused goal, which has been to provide more informed psychological help for the distress patients and their families experience when there is a diagnosis of cancer.

In 1991, I was the consulting psychiatrist to the Bone Marrow Transplant Unit at the University of Connecticut. I remember one mother of five young children who had come from Massachusetts for a transplant. Not only was the distance prohibitive for her family, but her youngest children couldn't visit because of the strict visiting rules to guard against infection. We tried in vain to work with the telephone company to use our BMT unit as a site for what was then a new way to videoconference so that the patient could see her children.

Today, there is more recognition of the emotional needs of patients with cancer and their families. I am grateful that the University of Michigan Cancer Center will be part of this exciting new frontier.

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Center Director Named to Newly Endowed Professorship

The leadership of Max S. Wicha, M.D., founding director of the University of Michigan Comprehensive Cancer Center, has been honored with a newly established endowed professorship at the U-M Medical School. The naming of Wicha as the first Distinguished Professor of Oncology recognizes his vision and commitment in leading the Center from its infancy to one of the premier centers in the country.
Max Wicha and Gil Omenn

The professorship will be held by the director and used to support important research programs. While Wicha serves as director, the professorship will be called the Distinguished Professorship in Oncology. When he steps down, it will then be known as the Max S. Wicha, M.D., Distinguished Professorship in Oncology.

The professorship was established through the generosity of Mrs. Geneva Maisel Kellman and major pledge commitments from John and Suzanne Munn, the Parke-Davis Pharmaceu-tical Research Division of the Warner-Lambert Company, and fund-raising efforts by the Cancer Center Development Committee.

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Research Roundup: Bone Marrow Transplantation

Targeting Neuroblastoma
Neuroblastoma is one of the most common childhood cancers and typically strikes children between the ages of 1 and 5. The disease often begins as a large mass growing along the backbone or within the abdomen. In more than 70 percent of cases, the tumor spreads to other parts of the body, such as the bones or bone marrow. "Despite all of our modern advances in medicine," says Gregory Yanik, M.D., pediatric oncologist at the U-M Cancer Center, "only one-quarter of children with advanced neuroblastoma are cured."

mother and child graphic

But new hope is being offered by a compound called metaiodobenzylguanidine (MIBG). In the 1970s, researchers discovered that MIBG reacts with more than 90 percent of neuroblastomas. Soon after, the U-M developed a method to trace MIBG throughout the patient's body using a special scanning process. This technique allows physicians to identify the exact sites where the neuroblastoma has spread.

Now U-M physicians, led by Yanik, are using MIBG to improve the effectiveness of a bone marrow transplant, which has become the standard treatment for patients with metastatic neuroblastoma. Typically radiation therapy or chemotherapy is given during the bone marrow transplant. However, neither treatment is tumor specific meaning healthy cells are affected along with tumor cells, which can lead to side effects. By using MIBG, which is tumor-specific, along with a bone marrow transplant, physicians at the U-M are able to target and attack only neuroblastoma cells.

"We hope this treatment will lead to improved survival with fewer complications for our patients," says Yanik. The University of Michigan Cancer Center is one of only two centers in the country using this technique.


Kinder, Gentler Transplants for Older Patients

Before undergoing an allogeneic transplant, cancer patients are given a high-dose "preparative" regimen of either chemotherapy or radiation to eliminate any cancerous cells, make room for new cells and destroy the immune system so it doesn't reject the new donor cells. But the irony of a bone marrow transplant is that the very treatment that's being given to save a patient's life can also lead to serious side effects or even death.

checking blood pressure
U-M researchers are looking at ways to lower the intensity of the preparative regimen without lowering its effectiveness. Based on findings from previous studies, U-M researchers are now offering a new regimen to patients with hematologic malignancies, such as leukemia and lymphoma, who are older than 55 and have less advanced forms of cancer.

"This group of patients is less likely to tolerate the standard preparative regimen and has a greater chance of developing complications," says Voravit Ratanatharathorn, M.D., principal investigator of this study.

Because there should be fewer complications, this approach will be more cost-effective as well as less taxing on patients.

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Harnessing the Immune System
New Bone Marrow Transplant Director Aims High

horse image

A pediatric oncologist who specializes in bone marrow transplantation, James Ferrara, M.D., believes the cure for many cancers lies in making the immune system our "faithful ally."

"The immune system is very powerful and very smart, but unreliable when it comes to fighting cancer," says Ferrara, professor of Medicine and Pediatrics, and newly appointed director of the U-M's Bone Marrow Transplantation Program. "We need to figure out how to make the immune system work the way we want it to, which I believe will lead to a cure faster than figuring out how to trick cancer cells into dying."

James (Jamie) Ferrara did not take the typical route from undergraduate to medical student. Instead, he studied the classics for several years at Oxford in England, before getting his medical degree at Georgetown University. Ferrara says studying the classics, in particular ancient ethics systems, has made him a better doctor.

"The ancient Greeks were passionate about life, and studying their culture helps one understand what it means to live 'the good life'," he explains. "I learned that the individual counts and that ideas really matter."

After medical school, Ferrara went on to train at Children's Hospital and the Dana Farber Cancer Institute in Boston, which is where he first became interested in bone marrow transplantation a relatively new therapy at that time. He stayed in the Boston area, most recently serving as associate professor of Pediatrics at Harvard Medical School.

For a number of years, Ferrara's research has focused on gaining a better understanding of the biological mechanisms of graft-versus-host disease and graft-versus-tumor effects in leukemia patients. Physicians know that a mild case of graft-versus-host disease an immune reaction caused when lymphocytes transplanted from a donor (the graft) reject the patient's body (the host) is a positive sign that the patient's leukemia is less likely to recur. A type of white blood cell called a T cell is thought to be responsible for this anti-leukemia effect, in conjunction with cytokines (special proteins) that are produced by the patient's body.

The goal of Ferrara's research is to harness the power of the graft-versus-tumor effect, while minimizing the potentially life-threatening consequences of advanced graft-versus-host disease.

"Years of laboratory research into this field have produced some very exciting results that are ready to be translated to the clinical setting where they can benefit our patients," says Ferrara. "I decided to come to the University of Michigan because I felt this was the best place in the country to do that."

One exciting area of investigation focuses on using the body's own wisdom to reduce the toxicity of transplant. Normally a protein in our blood called Interleukin 1 receptor antagonist (IL-1ra) reduces inflammation. Ferrara's research has shown that the level of the protein drops to about 20 percent of normal shortly after transplant and is significantly lower in patients with graft-versus-host disease (GVHD).

Laboratory research has shown that giving IL-1ra for 10 days can largely prevent GVHD. A randomized study with patients is now under way comparing standard treatment plus or minus IL-1ra. "We're very encouraged because the incidence of GVHD, particularly severe disease, seems to be reduced," he says.

In addition to his duties as a physician and researcher, Ferrara plans to make a number of changes to the program in his role as director.

"One of the challenges a wonderful change really is that we are combining the adult and pediatric transplant programs," says Ferrara. "The pieces are in place because the physicians' offices are next to each other and they work on the same teams, but they haven't truly integrated. I think doing so will improve the standard of care across the board."

Ferrara also will focus on building the areas of research and education. "The patient care here is excellent we perform more than 200 transplants each year but we can improve in our research and education. I'm looking forward to bringing on additional investigators, as well as improving training of physicians who will become the next generation of leaders in this field," Ferrara says.

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Cancer Center Offers Post-Treatment Breast Cancer Nutrition Classes

The flood of information about the relationship between cancer and diet can overwhelm cancer patients who have many other issues to think about during treatment. To help patients sort nutrition fact from fiction, the Cancer Center's Nutrition Services will offer classes to our breast cancer patients after they have completed their treatment, when they are better able to make lifestyle changes.

We will begin with breast cancer patients, but plan to offer classes for other patients in the future. Each course will include cooking classes, education about cancer-fighting foods and information about healthful lifestyle changes. The first six-week course begins April 13, and classes will meet every Tuesday from 1 to 3 p.m., at East Ann Arbor Health Center, 4260 Plymouth Road, Ann Arbor.

The cost for a six-week course is $150 (scholarships are available). To register, call Mary McCully at (734) 936-8307. Please note that class size is limited to 20 participants. Martha DeRoeck, M.S., R.D., Cancer Center Dietitian.

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MARCH Deemed a Success!

The MARCH:

For the first time, millions of Americans came together to fight the oldest, most-threatening disease known to man. On Sept. 25 and 26, cancer survivors, their families and friends united for a single, unprecedented effort: a rally in Washington, D.C., to demonstrate the need for increased funding for cancer research and treatment.

In conjunction with The MARCH: Coming Together to Conquer Cancer activities held in the nation's capital, the U-M Comprehensive Cancer Center sponsored several events for the local community.

Display booths were set up on the Mall in Washington with information on everything from pet therapy to the latest advances in cancer research. On the main stage, Aretha Franklin sang "When you Walk Through a Storm;" Jesse Jackson implored the crowd to change "Pain to Power;" and the honorary MARCH chairman, H. Norman Schwarzkopf, called on Congress to make the cause, the care and the cure for cancer a top national priority. National Childhood Cancer Awareness Quilt.

A highlight of the national event was the unveiling of the National Childhood Cancer Awareness Quilt. Cindy Crawford, whose brother died of cancer 20 years ago, helped to unfold the Wisconsin quilt. Dozens of quilts from across the nation were displayed with the faces of children who were still immersed in their battle with cancer, had finished their treatment, or had lost their fight.

Candle Lighting for Hope and Remembrance More than 300 people attended the Candle Lighting for Hope and Remembrance at the U-M Cancer Center's front entrance on Sept. 25, 1998. Families from throughout Michigan shared more than 800 names of loved ones who had died from cancer.

Michigan Marching Band

On Sept. 26, 100 cancer survivors - joined by Michigan's First Lady Michelle Engler, Mrs. Cathy Schembechler and Mrs. Laurie Carr - took the field with the Michigan Marching Band during a pre-game rally at the Michigan Stadium to raise awareness of cancer issues. The marchers, representing all ages and types of cancers, formed the international sign "against" as the band played "Lean On Me." Planes circling overhead carried banners encouraging people to become advocates in the fight against cancer. The stadium announcer reminded fans that only one penny out of every $10 we send to Washington, D.C., is spent on cancer research. When the marchers left the field, the crowd of more than 110,000 chanted along with the U-M cheerleaders "No More Cancer!"

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Spring to Life Benefit
Ford Motor Company Partners with U-M

The University of Michigan Comprehensive Cancer Center and Ford Motor Company have joined forces to host the ninth annual Spring to Life Brunch and art auction, which will be held at noon on Sunday, April 18, at the Morris Lawrence Building on the campus of Washtenaw Community College.

The benefit committee has been gathering a beautiful variety of art, including photography, jewelry, glass and paintings for this year's auction. Look for preview showings March 23 through April 10 at the Selo/Shevel, DeBoer and Chris Triola galleries in Ann Arbor and at Jacobson's in Briarwood Mall. The always-incredible brunch will be prepared by The Common Grill, Food For All Seasons, The Moveable Feast, Cousins Heritage Inn and award-winning chef Gary Danko.

Tickets for this year's event are $85/person ($60 tax-deductible gift) as a Donor, $150/person ($125 tax-deductible gift) as a Sponsor, or $250/person ($225 tax-deductible gift) as a Benefactor.

To make reservations or for more information, call Janet Roth or Kelley Altese at (734) 764-7170.

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Transplanting Courage

Danielle Popp was diagnosed with chronic myelogenous leukemia when she was six months pregnant. Her obstetrician noticed an elevated white blood cell count during her 26-week glucose-screening test. Referred to a hematologist/oncologist, Danielle began her journey as a cancer survivor. "At the time I had no idea what type of doctor that was or what those words meant. I was so wrapped up in being pregnant it did not even occur to me to ask," explains Danielle, age 28.

After deciding with her doctors that the best treatment option would be a peripheral blood stem cell transplant, Danielle's three brothers were tested to see if they would be compatible donors. Her brother Mark in California was found to be a perfect match.

Doctors continued following Danielle's counts. As long as her counts stayed stable, they would follow her until her due date. "So we waited. Every week my counts stayed at 35,000 I felt normal, very healthy," Danielle explains.

On May 22, 1997, Danielle delivered a healthy six pound, 13 ounce baby boy named Jacob. She nursed him for six weeks, and then overnight, her WBC count shot up to 50,000. Her hematologist in consultation with transplant doctors at the U-M Comprehensive Cancer Center decided to put Danielle on Hydrea_ to temporarily lower her counts until the transplant. The transplant needed to be done within the first year of diagnosis, and Danielle and brother Mark decided they would do it after the summer in September.

After Labor Day, Danielle was admitted to the U-M Hospital. Her brother arrived that same day from California. After a week of "conditioning" chemotherapy for Danielle and growth factor injections for Mark, the transplant was performed on Sept. 10. Stem cells were harvested from Mark by apheresis and transfused into Danielle through a central line in her chest.

According to Danielle, "The transplant was done right in my inpatient room on the transplant floor, just like a blood transfusion, very anticlimactic. My whole family was there." Her family was also there for her throughout treatment and the many months of recovery. Mark moved in with Danielle and her husband to take care of Jacob and drive Danielle back and forth to the hospital for her checkups. Other family members were always there to offer support and encouragement.

laptop computer Danielle found even more support on the Internet, on the Bone Marrow Transplant Talk List. She connected with more than 30 people who lived in different states. Danielle took her laptop computer with her everywhere, especially when she was an inpatient.

"If something strange was happening, I would put out a question on e-mail. Within a few hours, when I was ready to log back on, the answer was there," says Danielle. "The people online are just amazing. If they haven't had a similar experience, they have some other circumstance that fits. I found a lot of support from that list." She continues to correspond with many of these "cyber friends" to this day.

On the one-year anniversary of her transplant, Danielle decided to give something back for all the people who had supported her through her journey; she volunteered to become a peer counselor at the U-M Cancer Center. After a one-hour interview and a four-hour training and orientation session, Danielle was ready to share her experience with others in active treatment.

"We talk a lot about how I had a hard time going into the hospital when I was feeling normal whatever normal is to ultimately make myself so very sick so I could get well," explains Danielle. "I had to struggle with that for a long time. The person I'm counseling is experiencing the exact same thing right now." Possible hair loss, unrealistic expectations and coping with fatigue are other topics Danielle discusses.

"I found a lot of reassurance from the people I met online. Knowing that someone had been there, done it and survived someone else had experienced everything that I was experiencing. I think that is a huge part of the battle positive attitude got me through! I hope to pass that on to the people I counsel." Danielle believes that attitude is 90 percent of the battle, and she hopes to spread that message to everyone.

Maxine Solvay
Promotion Coordinator

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Glossary

(From Understanding Your Transplant, a publication of the U-M Cancer Center)

Apheresis - A blood-separating procedure in which blood is removed from a patient, sent through a special machine (where cells are separated and some are removed) and the remainder returned to the patient.

Conditioning
- The purpose of conditioning is to give high enough doses of chemotherapy and/or radiation to eliminate any cancerous cells that are present, to make room for the new cells and to destroy the immune system. This is done to prevent rejection of the new donor cells.

Growth Factor - an injectable drug used to stimulate the development of blood cells.

Peripheral Blood - circulating blood system.

Stem Cells - parent or seed cells in the bone marrow or circulating blood that produce all the different types of blood cells: white blood cells, platelets and red blood cells.

Transfusions - the infusion of any product derived from blood cells.

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The Peer Counseling Program

at the U-M Comprehensive Cancer Center matches patients with peer counselors according to diagnosis, treatment and lifestyle. Peer counselors share their experiences and insights with patients, and can listen and respond to fellow cancer survivors in a way no other health professional is able. For information on the Peer Counseling program, call the U-M Cancer Center Social Work office at (734) 764-3140.

"Being a peer counselor is probably as helpful to me as to the person I am counseling - knowing that I am helping someone, being there and making a difference in a positive way. It is my way of giving back."
- Danielle Popp
Cancer Survivor

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Editor

Max S. Wicha, M.D.
Director, U-M Cancer Center

Maria White
Director, Marketing Communications

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